Making sense of root cause analysis investigations of surgery-related adverse events.

Authors:
Dr Paul Barach, BSc, MD, MPH
Dr Paul Barach, BSc, MD, MPH
Wayne State University School of Medicine
Clinical Professor
Anesthesia, critical care
Chicago, IL | United States

Surg Clin North Am 2012 Feb;92(1):101-15

University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith South DC, New South Wales 1797, Australia.

This article discusses the limitations of root cause analysis (RCA) for surgical adverse events. Making sense of adverse events involves an appreciation of the unique features in a problematic situation, which resist generalization to other contexts. The top priority of adverse event investigations must be to inform the design of systems that help clinicians to adapt and respond effectively in real time to undesirable combinations of design, performance, and circumstance. RCAs can create opportunities in the clinical workplace for clinicians to reflect on local barriers and identify enablers of safe and reliable outcomes.

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.suc.2011.12.008DOI Listing
February 2012
29 Reads
2 Citations
1.880 Impact Factor

Publication Analysis

Top Keywords

adverse events
12
root analysis
8
making sense
8
top priority
4
clinical workplace
4
priority adverse
4
adverse event
4
investigations inform
4
event investigations
4
contexts top
4
generalization contexts
4
design performance
4
reflect local
4
features problematic
4
situation resist
4
clinicians reflect
4
inform design
4
resist generalization
4
workplace clinicians
4
systems help
4

Similar Publications